Author : Dr R Potgieter
Co author : Lizette Botha ( Chiropractic Masters Student )

I recently had the honour and privilege of being a spectator at the 2008 Ironman as was held on Sunday the 13th of April in Port Elizabeth.
Although a lot could be said about the race and the type of person that participate in an event like this, I must start by saying that it was a humbling experience. One could never be prepared to fully comprehend the immensity of the event and the inhuman physical demands placed on the athletes. So, without further ado, congratulations in the strongest possible terms to everybody that participated and especially to those that finished!!!!! To all my patients and friends that participated, you guys are machines!!!!!!!!

As was discussed in a previous issue, numerous mechanisms exist that could lead to myofascial pain and dysfunction syndromes. One of those mechanisms, extremely common in runners, is sacroiliac syndrome. To really understand this syndrome, we need to understand the anatomy and function of the SI joint.

The sacroiliac joint is the joint formed by the connection of the paired hip bones and the sacrum at the back of the pelvis. The sacrum is the lowermost part of the spine that is formed by the fusion of five vertebrae. There are two sacroiliac joints, one on each side of the sacrum, they articulate with the hip bones.

In the field of musculoskeletal medicine the sacroiliac joint has always been fraught with controversy; especially about its role in the production of musculoskeletal pain. In the early days of Hippocrates it was thought that the main role of the sacroiliac joint was its contribution to pelvic motion during childbirth. It was thus believed that no motion occurs in the sacroiliac joint, and thus was clinically insignificant. Recent contributions has recognized that motion does occur in the joint, even though some controversy still surrounds the amount of motion available, and the location of this axis of motion.

Sacroiliac dysfunction appears to still be a much overlooked condition that is still not recognized by clinicians involved in the diagnoses and treatment of mechanical low back pain. This could be due to the fact that the diagnosis of sacroiliac dysfunction still depends mainly on subjective clinical findings, the only gold standard for diagnosing sacroiliac pain being the relief of pain upon injection of a local anaesthetic. Yet many clinicians direct treatment to the sacroiliac joint and achieve relief of pain and associated symptoms.

When it comes to any joint in the body, structure and function is intimately related and thus should always be considered and assessed together. Thus when the sacroiliac joint is not functioning properly, especially pertaining to its mobility function, it will cause pain. Haldeman (1992) describes that a mobility dysfunction is the main cause of pain in the sacroiliac joint. Mobility dysfunction can be classified as either hypermobility (increased mobility) or hypomobility (decreased mobility).

1. SACROILIAC JOINT ANATOMY
The bony pelvis consists of the hip bones and the sacrum. The sacrum lies at the back of the pelvis and connect to the hip bones via paired sacroiliac joints. The sacrum is basically the "end" of the vertebral column, and is formed by five fused vertebrae. Some big nerves travel within a canal within the sacrum and exits via foraminae (holes) at the back of the sacrum to supply important muscles and organs within the pelvis. The coccyx is in turn attached to the bottom of the sacrum. The pelvic bones articulate with each other at the front to form the pubic symphysis. The paired sacroiliac joints at the back of the pelvis and the pubic symphysis at the front thus form a unit called a three joint complex. Thus when one of these joints is dysfunctional, it will inevitably cause compensation of the other joints in the complex.

The sacroiliac joint have a complex function, being that it needs to dissipate the weight of the upper body to the legs, and it has to be mobile to increase movement within the pelvis. It is thus important that the joint is stable without compensating its mobility.

The sacroiliac joint has a C-shape; this shape increases stability within the joint when it is compressed. The joint is comprised of two parts; the front part is covered by a synovial membrane with a thin layer of fluid that makes it very mobile, whilst the back part of the joint is made up by thick, short ligaments that warrants stability. The ligaments at the front of the joint are weaker than the ligaments at the back. No muscles in the pelvis has a direct connection to the sacroiliac joint, but about fifty muscles cross it and are affected by dysfunction within the joint.

There are ridges and depressions on the two articulating surfaces of the sacroiliac joint. These ridges and depressions are complementary in form and fit into each other like pieces of a puzzle. This increases stability within the joint. It is interesting to note that infants does not have this irregularities on their sacroiliac joint surfaces, it only starts developing during puberty due to the stress of weight bearing and ambulation. Females have less pronounced ridges and furrows than males.

The joint receives nervous supply from nerves that come from the lower spine and upper sacrum. It is also richly innervated by nerves called proprioceptors. Proprioceptors are nerve endings that perceive a structures position within space.

2. Sacroiliac Dysfunction
As described earlier, sacroiliac dysfunction is when the sacroiliac joint is not moving optimally, this is usually associated with pain. This happens when the opposing joint surfaces become locked onto each other, i.e. the ridges and furrows are no longer complementary. The wedging of the joint surfaces causes the surrounding muscles to become hypertonic and the ligaments to become taut.
Sacroiliac joint dysfunction can be due to a number of causes, eg. Trauma, overuse and abuse, camber and running shoes etc. etc. Patients usually describe twisting and bending motions that precipitated symptoms. Pregnancy and menstruation can also be a cause of sacroiliac dysfunction. This is due to the fact that the hormone Relaxin, secreted during pregnancy to soften the pelvic ligaments, is also secreted in small amounts during menstruation.

Patients describe the pain as dull and aching in nature. It is usually a one-sided pain that is located on either sides of the midline of the buttock area. If the patient experiences pain down his leg, it is usually located over the buttocks, posterior thigh, groin and lateral calf areas. Some patients may describe that the leg feels heavy and tired.

Patients also reports jabs of pain when coming upright or settling in a seated position, sitting for long periods is very painful. Rolling over in bed and bending sideways are also very uncomfortable.
When the patient is examined, it is noted that the ligaments and muscles surrounding the sacroiliac joint is tight. The hamstring muscles might also be very tight. None of these changes can be noted on radiographical examinations.

The musculoskeletal system is a biomechanical chain, when one segment is dysfunctional, it will inevitably affect segment higher up and lower down. One is likely to develop restriction of movement of some vertebral segments higher up in the spine, as well as in the hip and knee joint. When these biomechanical stresses are not addressed, severe complications like disc herniation of the lumbar spine may develop. This is due to the added rotary stresses on the spine. Chronic knee sprain and degeneration in the hip joint may occur. One is also at risk of developing scoliosis (a lateral curve of the spine).

Treatment of SI dysfunction:
The most effective treatment protocol will always be multi-disciplinary. Should the described symptom pattern fit your condition, the immediate approach would be to confirm possible abnormal biomechanics of the joint. Once that has been established, all vectors that led to the formation of the joint restriction and subsequent muscle syndromes must be identified and corrected.

1. Consult with a Chiropractor for a comprehensive examination to identify and isolate vector variables. Sacroiliac dysfunction is usually treated via specific joint manipulation. This consists of a high-velocity, short amplitude thrust that tends to stretch hypertonic muscles and restore normal motion within the joint. Most patients with sacroiliac dysfunction respond well to manipulation of the joint. One also has to keep in mind that the hypertonic muscles surrounding the joint might need some attention. Stretching, dry needling, massage etc will help ease the localized spasm of these muscles.

2. The myofascial component reacts well to Physiotherapy once the joint biomechanics have been normalized.

3. Kinematic chain abnormalities should be assessed and treated regionally. Consult with a Podiatrist as well as a Biokineticist to diagnose and address imbalances and structural anomalies.

4. I have recently been exposed to Kinesiology and I firmly believe in the effectiveness of this form of treatment for syndromes evolving from joint and muscle imbalances.

5. Pain management is essential due to the inflammatory nature of abnormal joint biomechanics.

6. Traumeel S therapy for the following reasons.